Issues

Stage Details

Legislation -
Bill Passed
(House)
(220-215) -
Nov. 7, 2009(Key vote)

Title: Health Care and Insurance Law Amendments

Vote Result

Yea Votes

Nay Votes

Vote Smart's Synopsis:

Vote to pass a bill that amends various statues related to health care and heath insurance coverage, including, but not limited to, the establishment of a public health insurance option and a Health Insurance Exchange Program, an individual mandate to purchase insurance, a surcharge on the adjusted gross income of individuals in the top income tax brackets, prohibiting insurers from denying coverage based on pre-existing conditions, a gradual elimination of the Medicare Part D coverage gap ("donut hole"), and an expansion of Medicaid eligibility.

Highlights:

Public Option and Health Insurance Exchange

Requires the Secretary of Health and Human Services to establish a public health insurance option that includes basic, enhanced, and premium benefit plans beginning in 2013, and specifies that enrollment in the public health insurance option is voluntary (Secs. 321 & 329).

Appropriates $2 billion for the purpose of establishing the public health insurance option, and requires the amount be repaid over a 10-year period beginning in 2013 (Sec. 322).

Requires the Secretary of Health and Human Services to establish geographically adjusted premium rates for the public health insurance option that are consistent with the premium rules established by the Health Choices Commissioner and at a level sufficient to finance the administrative costs and health benefits provided by the public health insurance option (Sec. 322).

Requires the Secretary of Health and Human Services to negotiate payment rates for the public health insurance option that are not lower than rates under Medicare and not higher than the average rates paid by other entities offering health benefit plans (Sec. 323).

Establishes a national Health Insurance Exchange program for the purpose of facilitating access to a variety of health benefit plans, and requires the Commissioner of the Health Choices Administration to do the following (Sec. 301):

Negotiate and enter into contracts with entities offering health benefit plans to participate in the Health Insurance Exchange;

Perform outreach and enrollment in such plans of Exchange-eligible individuals and employers;

Establish a risk pooling mechanism and consumer protections; and

Perform other required activities related to the Health Insurance Exchange.

Specifies that all individuals are eligible for coverage through the Health Insurance Exchange, unless he or she is enrolled in a health plan through an employer or has some form of "acceptable coverage" (Sec. 302).

Defines "acceptable coverage" as the following (Sec. 302):

Coverage under a qualified health benefit plan;

Grandfathered health insurance coverage, meaning coverage that is offered and effective before the effective date of the Health Insurance Exchange, or coverage under an existing group health plan;

Medicare or Medicaid coverage;

Coverage for members of the armed forces and dependents (including Tricare);

Coverage under the Veteran's Health Care Program; and

Other health benefits coverage, including a State health benefits risk pool, that is recognized by the Health Choices Commissioner, in coordination with the Secretary of the Treasury, as being "acceptable coverage."

Requires the Health Choices Commissioner to solicit bids from entities to offer health benefit plans through the Health Insurance Exchange, and requires the Commissioner to negotiate the premiums and affordability of such plans and deny any "excessive" premiums and premium increases (Sec. 304).

Specifies that individuals without coverage through an employer or through Medicare or Medicaid shall be eligible to enroll in the Health Insurance Exchange Program beginning in 2013, and business shall be eligible to enroll in the Exchange according to the following schedule (Sec. 302):

2013: small businesses with up to 25 employees;

2014: small business with up to 50 employees; and

2015 and subsequent years: small businesses with up to 100 employees, and larger employers meeting standards set by the Health Choices Commissioner.

Establishes the Health Insurance Exchange Trust Fund for the purpose of funding the Health Insurance Exchange, and requires that the revenue from the following taxes be deposited into the Fund (Sec. 307):

Taxes on individuals without "acceptable coverage";

Taxes on employers who do not elect to provide coverage to employees; and

Excise taxes on employers who elect to provide coverage to employees and fail to meet coverage requirements.

Authorizes 2 or more states to form a Health Care Choice Compact that would allow individuals to purchase health insurance offered in other states beginning January 1, 2015 (Sec. 309).

Requires the Health Choices Commissioner to establish a Consumer Operated and Oriented Plan (CO-OP) program for the purpose of providing grants and loans to non-profits that establish health insurance cooperatives that provide insurance through a federal or state health insurance exchange program, and appropriates $5 billion for this purpose for the period of fiscal year 2009-2010 through fiscal year 2013-2014 (Sec. 310).

Specifies that health care providers participating in Medicare are participating providers in the public health insurance option, unless they opt out in a process established by the Secretary of Health and Human Services with the following minimum guidelines (Sec. 323):

Providers must be able to opt out 1 year prior to the effective date of the public option;

No provider will be penalized for opting out;

Providers who chose to opt out must be given information on how they may opt back in; and

Providers can decide if they would like to participate or opt out during an annual enrollment period.

Specifies that individuals currently enrolled in an Exchange-participating health benefits plan may be eligible for "affordability credits" that can be applied against the premium and as a reduction in cost sharing, and establishes the following eligibility requirements for the credit (Secs. 342-343):

The individual is not enrolled in their employer's Exchange-participating health benefits plan;

The individual has a modified adjusted gross income below 400 percent of the Federal poverty level;

The individual is not eligible for Medicaid;

The individual does not have acceptable health coverage"; and

The individual can provide verification of their legal right to reside in the United States, and requires anyone applying for such credits to sign a declaration to this effect.

Specifies that "affordability credits" for premiums for the year of 2013 shall be calculated on a sliding scale as follows (Sec. 343):

For incomes between 0 percent and 150 percent, a premium percentage between 1.5 percent and 3 percent, and an out-of-pocket limit of $500;

For incomes between 150 percent and 200 percent, a premium percentage between 3 percent and 5.5 percent, and an out-of-pocket limit of $1,000;

For incomes between 200 percent and 250 percent, a premium percentage between 5.5 percent and 8 percent, and an out-of-pocket limit of $2,000;

For incomes between 250 percent and 300 percent, a premium percentage between 8 percent and 10 percent, and an out-of-pocket limit of $4,000;

For incomes between 300 percent and 350 percent, a premium percentage between 10 percent and 11 percent, and an out-of-pocket limit of $4,500; and

For incomes between 350 percent and 400 percent, a premium percentage between 11 percent and 12 percent, and an out-of-pocket limit of $5,000.

Requires the Commissioner to adjust the premium percentages for the "affordability credits" beginning in 2014 (Sec. 343).

Requires health insurers to offer coverage for children of an insured individual who are under 27 and are not enrolled in any other health insurance coverage beginning January 1, 2010 (Secs. 105 & 216).

Requires that insurers offering health coverage in small or large group markets to maintain a medical loss ratio of no less than 85 percent, and applies the same limit to coverage offered in the individual insurance market, unless the Secretary of Health and Human Services determines that this would destabilize the existing individual market (Sec. 102).

Requires the Secretary of Health and Human Services to work with the states to establish a process for the annual review of premium increases for health insurance coverage beginning in 2010, requires insurers to submit a justification for premium increases prior to their implementation, and requires public disclosure of information related to such increases and their justifications (Sec. 104).

Limits variation in premium rates based on age so that the ratio of the highest age-based premium to the lowest age-based premium does not exceed 2 to 1 (Sec. 213).

Prohibits group health plans from reducing benefits for a covered individual after the individual's retirement if the reductions do not also apply to covered individuals who are not retired, unless the employer can "reasonably" demonstrate that meeting the requirement would impose an "undue hardship" (Sec. 110).

Extends COBRA continuation coverage for individuals receiving such coverage on the effective date of this Act until the individual becomes eligible for "acceptable coverage" or for coverage through a federal or state health insurance exchange, whichever occurs first (Sec. 113).

Requires all health care and related services covered by this bill to be provided without regard to individual characteristics that are not related to the "provision of high quality health care or related services" (Sec. 252).

Prohibits employers from discharging or otherwise discriminating against any employee with regards to compensation, terms, conditions, or privileges of employment because the employee engaged in one of the following actions (Sec. 253):

Providing, causing to be provided, or intending to provide to the employer, the federal government, or the attorney general of a state information relating to any real or perceived violation of any provision of this bill;

Testifying or intending to testify in a proceeding concerning such a violation;

Assisting, participating, or intending to assist or participate in such a proceeding; or

Objecting to or refusing to participate in any activity, policy, practice, or task that is "reasonably" believed to violate a provision of this Act.

Repeals the exemption of federal antitrust laws for health insurers and medical malpractice insurers, and specifies that this provision shall not apply to the following (Sec. 262):

Determining a loss development factor applicable to historical loss data; or

Performing actuarial services if doing so does not involve a restraint of trade.

Requires the Secretary of Health and Human Services to establish a temporary national high-risk pool program to provide health benefits to eligible individuals beginning in 2010 and ending when the Health Insurance Exchange is established (Sec. 101).

Specifies that the following individuals are eligible for coverage under the high risk pool program (Sec. 101):

Individuals not eligible for benefits under Medicare, Medicaid, or SCHIP, or an employment-based health plan (not including a COBRA continuation provision), but who is eligible under existing laws guaranteeing coverage for certain individuals with prior group coverage (U.S. Code Title 42, § 300gg- 41) or is determined to be medically eligible, meaning the following:

During the 6 months prior to application for the high-risk program, the individual was denied coverage because of a preexisting condition or health status;

During the 6 months prior to application for the high-risk program, the individual was offered coverage under terms that limit coverage for a preexisting condition or at a premium rate that is above that of the high risk pool coverage; or

The individual has an eligible medical condition as defined by the Secretary of Health and Human Services;

The spouse of an individual who meets the above requirements;

Individuals that have not had health insurance coverage for at least 6 months prior to application for the high-risk program; or

Individuals that on or after October 29, 2009 had employment-based retiree health coverage with an annual increase in premiums that exceeds the threshold set by the Secretary of Health and Human Services as being excessive.

Appropriates $5 billion for the high risk pool program, and authorizes the Secretary of Health and Human Services to make adjustments such as reducing benefits, increasing premiums, or establishing waiting lists if the amount of funds proves to be insufficient during any fiscal year (Sec. 101).

Prohibits funds authorized or appropriated by this bill from being used to pay for any abortion or to cover any part of the costs of a health plan that includes abortion coverage, unless the woman would be placed in danger of death without the performance of an abortion or the pregnancy is the result of rape or incest (Sec. 265).

Employer and Individual Mandates

Establishes a 5.4 percent surcharge tax on income that exceeds the following (Sec. 551):

$1 million for individuals (not corporations); or

$500,000 for married individuals not filing a joint return.

Establishes an excise tax on the first taxable sale of medical devices equal to 2.5 percent of the sales price (Sec. 552).

Requires employers who elect to offer health insurance to provide coverage for the employee and employees' family, and if the employee elects to use their employer's health benefits plan, then employers must contribute 72.5 percent of the premium of the lowest cost individual coverage offered and 65 percent of the premium of the lowest cost family coverage offered (Secs. 411 & 412).

Specifies that for each employee who declines employer based coverage and instead enters the Health Insurance Exchange, employers must contribute a percentage of the average wages paid during the employee's enrollment to the Health Insurance Exchange Trust Fund as follows (Sec. 413):

0 percent of wages paid when annual payroll is $500,000 or less;

2 percent of wages paid when annual payroll is more than $500,000 but no more than $585,000;

4 percent of wages paid when annual payroll is more than $585,000 but no more than $670,000;

6 percent of wages paid when annual payroll is more than $670,000 but no more than $750,000; or

8 percent of wages paid when annual payroll is more than $750,000.

Requires employers that choose not to provide health insurance coverage for their employees to pay an excise tax equal to the following percentages of wages paid (Sec. 512):

0 percent of wages paid when annual payroll is $500,000 or less;

2 percent of wages paid when annual payroll is more than $500,000 but no more than $585,000;

4 percent of wages paid when annual payroll is more than $585,000 but no more than $670,000;

6 percent of wages paid when annual payroll is more than $670,000 but no more than $750,000; or

8 percent of wages paid when annual payroll is more than $750,000.

Authorizes the Secretary of Health and Human Services to asses a $100 fine for each day an employer purposefully fails to provide health coverage, provided that the employer elected to provide health care cover to their employees (Secs. 421 & 423).

Specifies that employers electing to provide health coverage but have failed to do, but are found to have exercised "reasonable diligence" and could not have known employees were not covered, will receive the following (Secs. 421 & 423):

A written notification from either the Secretary of Labor, the Secretary of the Treasury, or the Secretary of Health and Human Services, of a failure to provide health coverage to employees; and

If resolved within 30 days of discovering that such failure existed, no penalty will be incurred; or

If failures "due to reasonable cause" are not resolved within 30 days, a penalty not exceeding 10 percent of the total amount paid or incurred by the employer (or former employer) during the preceding 1-year period for group health plans or $500,000, whichever is less, in addition to any excise taxes the employer may already owe.

Specifies that individuals who do not obtain an "acceptable" form of health care coverage must pay a tax of 2.5 percent of the excess of the taxpayer's modified adjusted gross income over the amount of the taxpayer's gross income, an amount that cannot exceed the national average premium for self or family coverage (Sec. 501).

Specifies that dependents, documented non-resident immigrants, citizens living outside of the U.S., individuals living in U.S. territories, and citizens from recognized religious sects with conflicts of "religious conscience" shall not be required to pay an excise tax for failure to obtain "acceptable coverage" (Sec. 501).

Requires individuals to report on their tax returns, in addition to other required information, the names, addresses, and taxpayer identification numbers of each individual covered under the taxpayer's health care policy, and the length of time each individual has been covered under such policy (Sec. 501).

Provides certain small business owners with a health coverage credit of up to 50 percent of the employer's qualified employee health coverage expenses for the taxable year for 2 years (Sec. 521).

Increases the penalty for a non-qualified withdrawal from an individual's health savings account from 10 to 20 percent of the payment withdrawn (Sec. 533).

Specifies that the following medical services provided to Native Americans shall be excluded from gross income (Sec. 545):

Health services or benefits provided or purchased either directly or indirectly by the Indian Health Service;

Medical care provided by a Native American tribe or tribal organization to a Native American;

The value of accident or health plan coverage provided by a Native American tribe or tribal organization for medical care to a Native American; and

Any other medical care provided by a Native American tribe that supplements, replaces, or substitutes programs and services provided by the federal government.

Medicare and Medicaid

Eliminates the coverage gap under Medicare Part D that separates the limit on initial coverage and the coverage for catastrophic care ("donut hole") by 2019 as follows (Sec. 1181):

2019: initial coverage limit shall be increased 8 percent times the out-of-pocket gap amount, or other percentage as may be necessary to close the gap entirely.

Requires drug manufacturers to provide Medicare drug rebates for any covered Part D drug to individuals for which payment was made by a Prescription Drug Plan Sponsor under Part D or a Medicare Advantage Organization under Part C, including payments made through low-income and reinsurance subsidies (Sec. 1181).

Requires drug manufacturers to provide individuals subject to the Medicare Part D coverage gap with a discount of 50 percent on specific drugs beginning January 1, 2010 (Sec. 1182).

Requires the Secretary of Health and Human Services to negotiate with manufacturers regarding the prices of Part D drugs, including discounts, rebates, and other price concessions (Sec. 1186).

Increases the maximum amount of resources that an individual or married couple filing jointly may have in order to be eligible for the Medicare Savings Program or the Part D Low-Income Subsidy Program ("assets test") from $10,000 to $17,000 for singles, and from $20,000 to $34,000 for married couples filing jointly (Sec. 1201).

Prohibits Medicare Part D cost-sharing for full-benefit dual eligible individuals that are receiving care under a home and community based waiver who would otherwise require the level of care provided in a hospital, nursing facility, or intermediate care facility for the mentally disabled (Sec. 1202).

Requires the Secretary of Health and Human Services to reduce Medicare rates of payment to hospitals by specific amounts based upon their rates of "excess readmission" for 3 conditions selected by the Secretary with readmission measures that are endorsed by the National Quality Forum beginning in fiscal year 2010-2011, and requires the Secretary expand the number of conditions beginning in fiscal year 2012-2013 (Sec. 1151).

Eliminates cost sharing, including co-insurance and deductibles, for preventative services covered by Medicare, including, but not limited to, the following (Sec. 1305):

Prostate and colorectal cancer screenings;

Diabetes screenings;

Diabetes outpatient self-management training services;

Glaucoma screenings;

Medical nutrition therapy services;

Initial preventative physical examinations;

Cardiovascular screening blood tests;

Ultrasound screenings for abdominal aortic aneurysm;

Federally approved and recommended vaccines;

Mammography screenings;

Pap smear and pelvic exam screenings;

Bone mass measurements; and

Kidney disease education services.

Reduces Medicare Advantage rates of payment over the course of 3 years until they are equal to traditional Medicare fee-for-service levels beginning in 2011 (Sec. 1161).

Extends the authorization of the Secretary of Health and Human Services to adjust Medicare Advantage rates of payment to reflect differences in coding patterns between Medicare Advantage Plans and Medicare Part A and Part B plans for each year after 2010, whereas existing law only authorized the Secretary to do so through 2010 (Sec. 1162).

Expands Medicare Part B coverage to include all federally approved and recommended vaccinations that are covered by Medicare Part D (Sec. 1310).

Expands Medicare coverage to include voluntary advanced care planning consultations between enrollees and practitioners no more than once every 5 years, unless there is a significant change in the health or health-related condition of the individual, and specifies that such consultation may include, but is not limited to, the following (Sec. 1233):

Explanation of advance care planning, including a review of key questions and considerations, advance directives, including living wills and durable powers of attorney, and their uses;

Explanation of the role and responsibility of a health care proxy and of the continuum of end-of- life services and supports available, including palliative care and hospice, and benefits for such services and support; and

Explanation of physician orders regarding life sustaining treatment or similar orders in States where such orders exist.

Expands Medicaid eligibility to include individuals under 65 years of age with incomes that do not exceed 150 percent of the federal poverty level, including adults without children or a disability, and specifies that the federal government will compensate the States for 100 percent of the costs of covering these individuals in 2013 and 2014, and 91 percent of the costs in 2015 (Sec. 1701).

Prohibits States from adopting eligibility standards, methodologies, or procedures for their Children's Health Insurance Program (CHIP) that are a more restrictive than than the eligibility standards, methodologies, or procedures that are effective on June 16, 2009 (Sec. 1703).

Repeals the CHIP Program on January 1, 2014 (Sec. 1703).

Requires the Secretary of Health and Human Services to submit a report to Congress by December 31, 2011 that includes recommendations that are necessary to ensure that procedures are in effect for the enrollment of CHIP beneficiaries into a qualified health benefits plan offered through the Health Insurance Exchange or other coverage without interruption of coverage or a written plan of treatment (Sec. 1703).

Requires State Medicaid programs to cover, without cost-sharing, preventive services that are recommended with a grade A or B by the Task Force for Clinical Preventive Services, vaccines recommended by the Director of the Center for Disease Control and Prevention, and other preventative services deemed necessary by the Secretary of Health and Human Services for individuals eligible for Medicaid assistance beginning July 1, 2010 (Sec. 1711).

Increases Medicaid rates of payment to primary care practitioners to 80 percent of Medicare rates in 2010, 90 percent of Medicare rates in 2011, and 100 percent of Medicare rates in 2012 and subsequent years (Sec. 1721).

Specifies that all newborn children who otherwise do not have "acceptable coverage" are Medicaid eligible and shall receive such coverage until insured by another plan (Sec. 305).

Public Health and Workforce Development

Establishes the Public Health Investment Fund to support specific public health programs, and appropriates $33.9 billion to this Fund for fiscal year 2010-2011 through fiscal year 2014-2015 (Sec. 2002).

Authorizes an additional $12 billion in appropriations to community health centers for fiscal year 2010-2011 through fiscal year 2014-2015 (Sec. 2101).

Increases the amount a member of the National Health Service Corps can receive in loan repayment benefits from $35,000 to $50,000 (and provides for annual increases to reflect inflation beginning in fiscal year 2011-2012, and authorizes Corps members to serve part-time if such members agree to 1 of the following contracts (Sec. 2201):

Double the period of time necessary to fulfill service requirements; or

Serve a minimum of 2 years and accept 50 percent of the waiver awarded to full time service members.

Authorizes the appropriation of $349 million to the National Health Service Corps program for fiscal year 2010-2011 through fiscal year 2014-2015 (Sec. 2202).

Authorizes additional appropriations of $1.40 billion to the National Health Service Corps Scholarships and Loan Repayment Program fiscal year 2010-2011 through fiscal year 2014-2015 (Sec. 2202).

Establishes the Frontline Health Providers Loan Repayment Program to increase the number of health professionals in areas with a high need for health services and doctors, and specifies that an individual must serve for at least 2 years and must specialize in a health discipline that meets the designated area's needs in order to receive awards under the program (Sec. 2211).

Requires the Secretary of Health and Human Services to establish primary care training and capacity building programs that provide grants to accredited schools of medicine, especially for institutions with a record of training individuals from "disadvantaged backgrounds," institutions with a record of training a high percentage of individuals seeking to practice primary care medicine, institutions that have a record of placing graduates in under-served areas, and institutions that support teaching programs that address the health needs of "vulnerable populations" (Sec. 2213).

Requires the Secretary of Health and Human Services to create programs that increase grants to students of general medicine, pediatric medicine, public health dentists and dental hygienists, and for medical residents in community-based settings (Secs. 2214 & 2215).

Authorizes additional appropriations of $1.33 billion to carry out the grant programs specified in sections 2213, 2214, and 2215 (noted above) for fiscal year 2010-2011 through fiscal year 2014-2015 (Sec. 2216).

Increases the limits on loan reimbursement payments for nursing students, including an increase in the limit on the aggregate of loans from all academic years for students from $13,000 to $17,000, removes the limit on awards for nursing students working towards a doctoral degree, and authorizes appropriations of $638 million for nursing programs for fiscal year 2010-2011 through fiscal year 2014-2015 (Sec. 2221).

Establishes the Public Health Workforce Corps for the purpose of "ensuring an adequate supply of public health professionals throughout the Nation" and authorizes the appropriation of $283 million for the Corps for fiscal year 2010-2011 through fiscal year 2014-2015 (Secs. 2231 & 2235)

Establishes a public health workforce training and enhancement program to plan, develop, operate, and provide financial assistance to public health training programs, especially those that train individuals from disadvantaged backgrounds, those that train individuals in specialties experiencing public health professional shortages, those that train a high percentage of people serving in federal, state, local, or tribal government, and those that train a high percentage of people practicing in "underserved communities" (Sec. 2232).

Increases the limit on educational loan funding for individuals from "disadvantaged backgrounds" training to serve as health professionals who agree to serve as faculty at eligible health professions schools from $20,000 to $35,000 per year (Sec. 2241).

Establishes the Prevention and Wellness Trust to fund the national strategy adopted by the Secretary of Health and Human Services for improving the Nation's health through evidence-based clinical and community prevention and wellness activities, and authorizes the appropriation of $15.4 billion for the Trust for fiscal year 2010-2011 through fiscal year 2014-2015 (Sec. 2301).

Requires chain restaurants with 20 or more locations to post nutritional information of menu items, including calorie content, on the menu (Sec. 2572).